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Decompressive craniectomy for the treatment of malignant infarction of the middle cerebral artery.

ABSTRACT: Early decompressive craniectomy (DC) has been shown to reduce mortality in malignant middle cerebral artery (MCA) infarction, whereas efficacy of DC on functional outcome is inconclusive. Here, we performed a meta-analysis to estimate the effects of DC on malignant MCA infarction and investigated whether age of patients and timing of surgery influenced the efficacy. We systematically searched PubMed, Medline, Embase, Cochrane library, Web of Science update to June 2014. Finally, A total of 14 studies involved 747 patients were included, of which 8 were RCTs (341 patients). The results demonstrated that early DC (within 48 h after stroke onset) decreased mortality (OR = 0.14, 95%CI = 0.08, 0.25, p<0.0001) and number of patients with poor functional outcome (modified Rankin scale (mRS)>3) (OR = 0.38, 95%CI = 0.20, 0.73, p = 0.004) for 12 months follow-up. In the subgroup analysis stratified by age, early DC improved outcome both in younger and older patients. However, later DC (after 48h after stroke onset) might not have a benefit effect on lowering mortality or improving outcome in patients with malignant infarction. Together, this study suggested that decompressive surgery undertaken within 48 h reduced mortality and increased the number of patients with a favourable outcome in patients with malignant MCA infarction.

SUBMITTER: Lu X

PROVIDER: S-EPMC4233335 | biostudies-literature | 2014 Nov

REPOSITORIES: biostudies-literature

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Decompressive craniectomy for the treatment of malignant infarction of the middle cerebral artery.

Lu XiaoCheng X Huang BaoSheng B Zheng JinYu J Tao Yi Y Yu Wan W Tang LinJun L Zhu RongLan R Li Shuai S Li LiXin L

Scientific reports 20141117

Early decompressive craniectomy (DC) has been shown to reduce mortality in malignant middle cerebral artery (MCA) infarction, whereas efficacy of DC on functional outcome is inconclusive. Here, we performed a meta-analysis to estimate the effects of DC on malignant MCA infarction and investigated whether age of patients and timing of surgery influenced the efficacy. We systematically searched PubMed, Medline, Embase, Cochrane library, Web of Science update to June 2014. Finally, A total of 14 st ...[more]

PMID: 25400113

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Project description:BackgroundMalignant middle cerebral artery infarction (MMI) is associated with a high incidence of severe disability and mortality. Decompressive hemicraniectomy has become a recognized treatment that can improve the prognosis for patients if performed within a certain time window. Nevertheless, despite this intervention, a mortality rate of approximately 20-40% persists following the surgery. The trends and clinical implications of intracranial pressure (ICP) in these situations remain unclear. We aimed to investigate whether intracranial pressure (ICP) trends are associated with clinical outcomes in patients undergoing decompressive hemicraniectomy for MMI.MethodsThis retrospective cohort study included consecutive patients with MMI who underwent decompressive craniectomy and received ICP monitoring after surgery. Using a linear mixed model, we categorized the patients into ICP increase and decrease groups based on the ICP values obtained over 192 h. We then compared the proportion of 3-month favorable outcomes (modified Rankin Scale of 0-4) and mortality rates between these groups.ResultsOf 112 MMI patients who underwent decompressive hemicraniectomy, 66 (58.9%) received invasive ICP monitoring. ICP monitoring was performed for a median of 146.5 h (IQR 72.5-181.8). Among the 66 patients, 37 (56.1%) were in the ICP increase group, and 29 (43.9%) were in the ICP decrease group. During the monitoring period, the initial monitored ICP and peak ICP did not significantly differ between the ICP increase and decrease groups. However, the ICP trend was significantly different between the two groups (P < 0.001). In multivariable logistic regression analyses, the ICP increase group had a significantly lower proportion of 3-month favorable outcomes compared to the ICP decrease group (adjusted OR 0.11; 95% CI, 0.01-0.59; P = 0.019), and significantly higher mortality in the intensive care unit (adjusted OR 6.98; 95% CI, 1.37-54.6; P = 0.031).ConclusionsIn MMI patients, continuous ICP monitoring could be useful for detecting those with an increasing ICP trend that may be associated with unfavorable clinical outcomes.

Project description:BackgroundMalignant middle cerebral artery infarction is a potentially life-threatening disease. Decompressive hemicraniectomy constitutes an evidence-based treatment practice, especially in patients under 60 years of age; however, recommendations with respect to postoperative management and particularly duration of postoperative sedation lack standardization.ObjectiveThis survey study aimed to analyze the current situation of patients with malignant middle cerebral artery infarction following hemicraniectomy in the neurointensive care setting.Material and methodsFrom 20 September 2021 to 31 October 2021, 43 members of the initiative of German neurointensive trial engagement (IGNITE) network were invited to participate in a standardized anonymous online survey. Descriptive data analysis was performed.ResultsOut of 43 centers 29 (67.4%) participated in the survey, including 24 university hospitals. Of the hospitals 21 have their own neurological intensive care unit. While 23.1% favored a standardized approach regarding postoperative sedation, the majority utilized individual criteria (e.g., intracranial pressure increase, weaning parameters, complications) to assess the need and duration. The timing of targeted extubation varied widely between hospitals (≤ 24 h 19.2%, ≤ 3 days in 30.8%, ≤ 5 days in 19.2%, > 5 days in 15.4%). Early tracheotomy (≤ 7 days) is performed in 19.2% and 80.8% of the centers aim for tracheotomy within 14 days. Hyperosmolar treatment is used on a regular basis in 53.9% and 22 centers (84.6%) agreed to participate in a clinical trial addressing the duration of postoperative sedation and ventilation.ConclusionThe results of this nationwide survey among neurointensive care units in Germany reflect a remarkable heterogeneity in the treatment practices of patients with malignant middle cerebral artery infarction undergoing hemicraniectomy, especially with respect to the duration of postoperative sedation and ventilation. A randomized trial in this matter seems warranted.

Project description:BackgroundModerate hypothermia after decompressive surgery might not be beneficial for stroke patients. However, normothermia may prove to be an effective method of enhancing neurological outcomes. The study aims were to evaluate the application of a pre-specified normothermia protocol in stroke patients after decompressive surgery and its impact on temperature load, and to describe the functional outcome of patients at 12 months after treatment.MethodsWe analysed patients with space-occupying middle cerebral artery (MCA) infarction treated with decompressive surgery and a pre-specified temperature management protocol. Patients treated primarily with device-controlled normothermia or hypothermia were excluded. The individual temperature load above 36.5 °C was calculated for the first 96 h after hemicraniectomy as the Area Under the Curve, using °C x hours. The effect of temperature load on functional outcome at 12 months was analysed by logistic regression.ResultsWe included 40 stroke patients treated with decompressive surgery (mean [SD] age: 58.9 [10.1] years; mean [SD] time to surgery: 30.5 [16.7] hours). Fever (temperature > 37.5 °C) developed in 26 patients during the first 96 h after surgery and mean (SD) temperature load above 36.5 °C in this time period was 62,3 (+/- 47,6) °C*hours. At one year after stroke onset, a moderate to moderately severe disability (modified Rankin Scale score of 3 or 4) was observed in 32% of patients, and a severe disability (score of 5) in 37% of patients, respectively. The lethality in the cohort at 12 months was 32%. The temperature load during the first 96 h was not an independent predictor for 12 month lethality (OR 0.986 [95%-CI:0.967-1.002]; p < 0.12).ConclusionsTemperature control in surgically treated patients with space-occupying MCA infarction using a pre-specified protocol excluding temperature management systems resulted in mild hyperthermia between 36.8 °C and 37.2 °C and a low overall temperature load. Future prospective studies on larger cohorts comparing different strategies for normothermia treatment including temperature management devices are needed.

Project description:ImportanceModerate hypothermia in addition to early decompressive hemicraniectomy has been suggested to further reduce mortality and improve functional outcome in patients with malignant middle cerebral artery (MCA) stroke.ObjectiveTo investigate whether moderate hypothermia vs standard treatment after early hemicraniectomy reduces mortality at day 14 in patients with malignant MCA stroke.Design, setting, and participantsThis randomized clinical trial recruited patients from August 2011 through September 2015 at 6 German university hospitals with dedicated neurointensive care units. Of the patients treated with hemicraniectomy and assessed for eligibility, patients were randomly assigned to either standard care or moderate hypothermia. Data analysis was completed from December 2016 to June 2018.InterventionsModerate hypothermia (temperature, 33.0 ± 1.0°C) was maintained for at least 72 hours immediately after hemicraniectomy.Main outcomes and measuresThe primary outcome was mortality rate at day 14 compared with the Fisher exact test and expressed as odds ratio (ORs) with 95% CIs. Rates of patients with serious adverse events were estimated for the period of the first 14 days after hemicraniectomy and 12 months of follow-up. Secondary outcome measures included functional outcome at 12 months.ResultsOf the 50 study participants, 24 were assigned to standard care and 26 to moderate hypothermia. Twenty-eight were male (56%); the mean (SD) patient age was 51.3 (6.6) years. Recruitment was suspended for safety concerns: 12 of 26 patients (46%) in the hypothermia group and 7 of 24 patients (29%) receiving standard care had at least 1 serious adverse event within 14 days (OR, 2.05 [95% CI, 0.56-8.00]; P = .26); after 12 months, rates of serious adverse events were 80% (n = 20 of 25) in the hypothermia group and 43% (n = 10 of 23) in the standard care group (hazard ratio, 2.54 [95% CI, 1.29-5.00]; P = .005). The mortality rate at day 14 was 19% (5 of 26 patients) in the hypothermia group and 13% (3 of 24 patients) in the group receiving standard care (OR, 1.65 [95% CI, 0.28-12.01]; P = .70). There was no significant difference regarding functional outcome after 12 months of follow-up.InterpretationIn patients with malignant MCA stroke, moderate hypothermia early after hemicraniectomy did not improve mortality and functional outcome compared with standard care, but may cause serious harm in this specific setting.Trial registrationhttp://www.drks.de, identifier DRKS00000623.

Dataset Information

Decompressive craniectomy for the treatment of malignant infarction of the middle cerebral artery.

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Decompressive craniectomy for the treatment of malignant infarction of the middle cerebral artery.

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